Friends of nursing: a community of caring to promote excellence in nursing practice, education, and research

More than 25 years ago, the name "Friends of Nursing" was adopted by an academic, community Magnet(?) hospital to signify a model for community support of nursing. From inception, the intent was to recruit philanthropic dollars to promote recognition of and excellence in nursing practice, education, and research. Although philanthropy in health care settings is common, what is unique about this program is the long-standing, dedicated conceptual framework for nursing philanthropy and the very significant number of philanthropic dollars from literally thousands of donors to support a diverse range of activities to affect and advance the professional excellence of nurses and the quality of patient care. This model has been successfully replicated within a wide variety of other health care organizations and nursing services throughout the United States and abroad.     

A causal model of health services for diabetic patients

A causal model of health services which includes patient and provider variables, perceived access to care, utilization of services, continuity of care, technical quality of the care process, technical quality of the care outcome, and patient satisfaction is applied to a group of diabetic patients enrolled in the Seattle Prepaid Health Care Project. The enrollees received comprehensive health services at zero out-of-pocket cost from either a prepaid group practice plan or an independent practice plan. Surveys were periodically conducted to determine health status, satisfaction, and demographic characteristics of the enrollees; utilization of services was monitored throughout the experiment. The causal model is operationalized through the use of path analysis. Significant relationships (p less than or equal to .10) were established between satisfaction and perceived access to care, family size, sex, and professional qualifications of the provider; between outcome of care and health status, female education, and physician performance; between physician performance and professional qualifications; between continuity of care and health status and female education; between utilization and perceived access, specialty of provider, and provider system; and between access to care and provider system. The policy implications of the results are discussed.     

The Collaborative Health Care Team: The Role of Individual and Group Expertise

Background: Increasing costs of health care and rapid knowledge growth have led to collaboration among health care professionals to share knowledge and skills. Purposes: To characterize the qualitative nature of team interaction and its relation to training health professionals, drawing on theoretical and analytical frameworks from the sociocognitive sciences. Methods: Activities in a primary care unit were monitored using observational field notes, hospital documents, and audio recordings of interviews and clinical interactions. Results: The demarcation of responsibilities and roles of personnel within the team became fuzzy in practice. Continuous care was provided by primary care providers and specialized care by intermittent consultants. The nature of individual expertise required was a function of the patient problem and the interaction goal. These team characteristics contributed to the reduction of unnecessary and redundant interactions. Conclusions: Distributed responsibilities allow the team to process massive amounts of patient information, reducing the cognitive load on individuals. The uniqueness of individual professional expertise as it contributes to the accomplishment of team goals is highlighted, suggesting emphasis on conceptual competence in the development of individual professional education programs.     

Clinical preventive medicine in primary care: background and practice: 2. Delivering primary preventive services

Strategies to incorporate preventive services into primary care settings have been underutilized. The first component of delivering preventive services in the primary care setting is the health risk assessment followed by establishment of practice guidelines and protocols for preventive services--who is eligible for what service (based on age, sex, and other clinical characteristics) and when. A computerized reminder system can be useful to track past and currently due preventive services for each patient and can also serve as a follow-up system for test results. Well-trained paramedical personnel can perform appropriate patient counseling and education. The goal of counseling and education is to change patient behavior. The first step in this difficult process is once again to ascertain health risks and then to determine the patient's stage of readiness--defined as precontemplation, contemplation, preparation, action, and maintenance. The counselor assists in identification of target behavior, advocates and commends behavior change, reinforces health benefits of behavior change, offers resources, strategies, and support, and creates a plan of action and monitoring mechanisms. Improved implementation of preventive services in primary care could have a major impact on the health of the population.     

The whys of patient education

The rationale for patient education is that patients and families have the right to be informed; that professional standards describe appropriate patient education; that health care organizations and the law require patient education; and patients, health care organizations, and that society benefit from the process. Patients with cancer benefit in terms of knowledge acquisition, enhanced self-care, reduced anxiety, enhanced self-concept and self-esteem, increased satisfaction with care, improved pain control, improved oral status, and reduced disruption in daily functioning. Health care organizations benefit in terms of quality services, reduced costs, and reduction in malpractice suits. Society benefits as patients with knowledge and skills maintain or resume functional status and return to school, work, or service activities. Nurses are key professionals in the coordination and delivery of patient education programs. They too have the opportunity to benefit from patient education through therapeutic alliances with patients and families that foster both personal and professional satisfaction.     

Development of an academic-practice partnership model to anchor care coordination and population health

The National Academy of Medicine's The Future of Nursing 2020–2030 recommends the expansion of the role of nurses throughout the continuum of health care in an effort to improve the health of the nation while decreasing costs. To accomplish this goal, nursing students and nurses must be well prepared to perform at their highest capacity to meet health care demands. Currently the U.S. health care delivery system is undergoing rapid changes that affect approaches to delivering care services. These changes call for education and practice reforms in nursing. This article introduces an innovative academic-practice partnership model (the University of Maryland Nursing [UMNursing] Care Coordination Implementation Collaborative), including its background, development, and blueprint for a large implementation project. The implementation model integrates nursing education and practice in areas of care co-ordination and population health, which have a significant impact on the Triple Aim of health. The project also uniquely integrates education, practice, and research, with the ultimate outcome of higher quality patient care.     

Health care information systems. Patient-centered integration is the key

In today's cost-constrained health care delivery environment, hospitals are recognizing the need to optimize their care operations to improve the efficiency, efficacy, and service quality of primary health care providers, particularly the medical staff and nursing services, which comprise about 50% of the hospital's total personnel. Because health care institutions are in the business of caring for patients (not for accounts or departments), and because health care delivery largely is a personnel-intensive information industry, operations optimization is supported best by information systems that fully integrate all information concerning the patient. The goal of this is to simplify the job duties of direct care providers. The benefits of an integrated, patient-centered approach include demonstrable improvements in over-all patient care quality and staff satisfaction as well as a significant reduction in costs.     

What we know and what they do: nursing students' experiences of improvement knowledge in clinical practice

Nations around the world face mounting problems in health care, including rising costs, challenges to accessing services, and wide variations in safety and quality. Several reports and surveys have clearly demonstrated that adverse events and errors pose serious threats to patient safety. It has become obvious that future health professionals will need to address such problems in the quality of patient care. This article discuss a research study examining improvement knowledge in clinical practice as experienced by nursing students with respect to a patient-centred perspective, knowledge of health-care processes, the handling of adverse events, cross-professional collaboration, and the development of new knowledge. Six focus groups were conducted, comprising a total of 27 second-year students. The resulting discourses were recorded, coded and analysed. The findings indicate a deficiency in improvement knowledge in clinical practice, and a gap between what students learn about patient care and what they observe. In addition the findings suggest that there is a need to change the culture in health care and health professional education, and to develop learning models that encourage reflection, openness, and scrutiny of underlying individual and organizational values and assumptions in health care.     

Building a mission for quality care.

Clearly, there is a benefit to the group process in helping to establish teamwork. Teamwork and cooperation can assist with promoting effective communication, improving work quality, and building a sense of well-being within the group. With this cooperation, setting goals and looking toward the future can become a reality. Once goals are set, then developing a professional image can begin. Developing a mission statement can be an effective means to help create that professional image. Having the opportunity to develop a mission for a patient care area and articulating it through a mission statement coalesces the values, beliefs, and philosophy of a group of neuroscience staff. The following is the mission statement developed by the neurosciences unit at the University of Wisconsin Hospital and Clinics: We, the staff of UWHC Neuroscience unit embrace a vision of excellence in health care for all. Our mission is to deliver consistent quality patient care, while fostering our own professional growth. As caring healers, teachers and patient advocates in an ever-changing health care environment, we are empowered by the code for nurses. Within our scope of practice, we strive to maintain a balance of basic human respect and dignity for patients and their families in their quest for wellness, adaptation, rehabilitation or comfort care. It is our hope that patients and families will work with the health care team to construct a plan of care that best meets the patient's needs and goals. We are committed to accommodate special communication, religious or cultural needs of patients and their families. Our final acknowledgment is to ourselves, as members of the health care team. We celebrate the dignity of the staff by recognizing each individual as a special person capable of making unique and significant contributions to the unit.     

Problematizing health coaching for chronic illness self‐management

To address the growing costs associated with chronic illness care, many countries, both developed and developing, identify increased patient self‐management or self‐care as a focus of healthcare reform. Health coaching, an implementation strategy to support the shift to self‐management, encourages patients to make lifestyle changes to improve the management of chronic illness. This practice differs from traditional models of health education because of the interactional dynamics between nurse and patient, and an orientation to care that ostensibly centres and empowers patients. The theoretical underpinnings of coaching reflect these differences, however in its application, the practices arranged around health coaching for chronic illness self‐management reveal the social regulation and professional management of everyday life. This becomes especially problematic in contexts defined by economic constraint and government withdrawal from activities related to the ‘care’ of citizens. In this paper, we trace the development of health coaching as part of nursing practice and consider the implications of this practice as an emerging element of chronic illness self‐management. Our purpose is to highlight health coaching as an approach intended to support patients with chronic illness and at the same time, problematize the tensions contained in (and by) this practice.     

Determining frameworks for interprofessional education and core competencies through collaborative consultancy: the CARE experience

It is claimed that an interprofessional approach to health care aims to provide optimal client care, reduce duplication of services, address gaps in service delivery and prevent adverse consequences to patients. Hence there is widespread international interest in interprofessional education in undergraduate programs. However, after employment in the Australian health care workforce, there is limited opportunity for this. The continued education and training of health professionals and other care workers frequently occurs in a climate where professional development is dominated by the existence of professional demarcations. In order to enhance interprofessional collaboration in health care practice and education, mechanisms to guide individual performance within a multi-professional health team are required. This paper presents both the process and outcomes of a consultancy undertaken in order to determine core competencies for collaborative interprofessional practice in a community and aged care service.     

Comprehensive risk assessment for adolescents in school-based health centers

Providing comprehensive clinical services in school-based health centers affords the advanced practice nurse the opportunities for professional growth and fulfillment. Nurse practitioners are the primary clinician in the majority of SBHCs [1]. A substantial body of knowledge exists supporting the needs of adolescents, as well as methods by which nurse practitioners may assess, document, and intervene in order to improve health outcomes in this age group. To help move the field of school-based health care from innovation to mainstream, nurse practitioners need to continue to be part of the development of conceptual frameworks, appropriate methods, and evaluation of the process and outcomes. Educational achievement, access to care and reimbursement, and reduction of adolescent morbidity are indicators that have great significance in policy development. The extent to which nurse practitioners in SBHCs can provide evidence of making a difference will determine the success of this important health care venue for adolescents and demonstrate their own professional excellence.     

Medicare funding for nursing education: proposal for a coherent policy agenda

Medicare Graduate Medical Education (GME) funding for nursing education, established in 1965, no longer represents a coherent policy agenda, which must support educating the nursing workforce from classroom to practice. Three key concepts must be addressed: nursing education costs for both service and educational institutions, defining nursing education in federal rules and regulations, and the community's role in supporting nursing education. Responsibility for educating a nursing workforce must be shared by the community of academic, health care, professional, and government institutions and organizations, a policy supported by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). Knowledge about costs, funding streams, and policies for nursing education is essential for nursing educators to advocate for funding of nursing education and practice. Nursing programs and academic institutions need to initiate discussions with policy makers and potential community partners about service/education partnerships. Finally, community investment in nursing education pays dividends by providing essential health services of a highly skilled professional workforce.     

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.     

Interprofessional learning and higher education structural barriers

Structural changes need to be made within universities such that interprofessional education for patient-centred collaborative practice becomes a responsibility that crosses faculty jurisdictions and is accepted as the responsibility of all associated health and human service programs. In communities, the patient or client is the centre of professional attention requiring care that goes beyond the skill and scope of any one profession. Notions about collaboration inform and drive interprofessional education and should lead to sustainable system changes within centres of advanced education that ensure a permanent place for interprofessional education in all health and human service programs. This chapter explores the many barriers to achieving this goal, and offers insights into their removal from one university's experience.     

A case study exploring the ethical and policy dimensions of allocating acute care resources to a dying patient

Aims. We aimed to identify policy, process and ethical issues related to allocation of National Health Service resources when patients with end‐of‐life illness are referred to acute care services. Background. Sharing healthcare decisions denotes a different partnership between professionals and patients when patients are empowered to define their needs. Implementation of a transition from professional to patient decision‐making appears to be dependent upon its interpretation by personnel delivering care using the local trust policy. The outcome of this is a reformation of responsibility for budget allocation, choice of acute care provider and selecting services, currently in the realm of primary care; be it the general practitioner, community practitioners, or the patient. Design. We used a ‘lens’ approach to case study analysis in which the lens is constructed of a model of policy analysis and four principles of biomedical ethics. A patient's decision to decline care proposed by an Accident and Emergency department nurse and the nurse's response to that decision expose a policy that restricts the use of ambulance transport and with that, flexibility in responses to patients’ decisions. Findings. End‐of‐life care partnership decisions require sensitivity and flexibility from all healthcare practitioners. We found that policy‐based systems currently used to deliver care across the primary care – hospital care border are far from seamless and can lead to foreseeable problems. Conclusions. Health professionals responsible for the care of a patient at the end of life should consider the holistic outcomes of resource allocation decisions for patients. Relevance to clinical practice. Government and health professional agenda suggest that patients should be given a greater element of control over their healthcare than has historically been the case. When patients take responsibility for their decisions, healthcare personnel should recognize that this signals a shift in the nature of the professional–patient relationship to one of partnership.     

Developing advanced rural nursing practice: a whole new scope of responsibility

Rural registered nurses’ experiences of advanced clinical nursing practice were explored whilst they were enrolled in an advanced primary care course of study. Thirty-two nurses employed in rural health services in Victoria, Australia, studied advanced practice nursing by distance education with a clinical component. At course conclusion, focus groups and a quantitative on-line survey were conducted to explore outcomes. Nurses reported positive self-perceptions of their educational preparation with scores of >7/10 for competence, confidence, preparedness for advanced practice and job satisfaction. Focus group discussions concurred with positive survey results. The course was valuable in developing skills and knowledge, enabling more holistic patient care. The main themes that emerged related to the advancement of the nurse as a professional, and enhancement of patient care. Within their scope of practice, nurses assessed, diagnosed and treated minor patient illness presentations either independently or collaboratively with medical advice. The context of rural health services dictated practice and levels of autonomy. Nurses perceived the new role reduced an overload of medical work, whilst increasing patients’ access to care. As a result of the course 24% of participants reported a change in their work role. Nurses employed in rural health services reported positive potential for advanced collaborative practice in rural health care, in association with medical professionals. Defined role boundaries, role responsibilities and dedicated advanced practice positions will be required to achieve implementation of the role.     

Healthcare students as innovative partners in the development of future healthcare services: An action research approach

BackgroundHealth care systems in Norway and the western world have experienced extensive changes due to patients living longer with complex conditions that require coordinated care. A Norwegian healthcare reform has led to significant restructuring in service delivery as a devolution of services to municipalities.Action Research DesignPartners from three rural healthcare services, students from four professional programmes, and one lecturer from each of the professional programmes used a collaborative approach to obtain new knowledge through interprofessional practice. Using an action research design, the research group facilitated democratic processes through dialogues with healthcare services and students. The design is visualised as a cyclical process in which each cycle contributes to improvements, innovations, and increased understanding. A total of 32 students and 3 supervisors were interviewed before and after the clinical practice experiences. Fieldwork was conducted during three clinical periods.FindingsInterprofessional student groups formed small healthcare teams and assessed patients with chronic and long-term conditions. Students prepared and negotiated patient follow-up. The teams' responsibilities led to reflective practices that enhanced their professional knowledge. The teams achieved a new understanding of patient situations, which influenced “second opinions” for patients with complex conditions and led to innovative practices. The change in perception of patient needs led to a changed professional approach. The students' perceptions changed as they learned from and about each other and in collaboration with the health service; this led to more coordinated care of patients with complex conditions. Interprofessional learning in community settings provided a platform to improve both healthcare education and rural healthcare services.ConclusionThis research contributes to knowledge of how students' placement in interprofessional teams can enhance students learning from, with and about each other. The student teams promoted new ways of approaching and delivering complex patient treatment and care in community healthcare service. Collaborative partnerships in interprofessional learning have potential in the wider international arena as a means for practice improvement.     

Patient participation — a review of the literature

? This article presents a critical review of the concept of patient participation. ? The concept of patient participation has become widely accepted in contemporary nursing practice. It is now part of the vocabulary of professional nurses and has been heralded as a means of enhancing decision making and human dignity and enriching quality of life. ? Patient participation in care is emerging as a growing movement wherein patients are assuming more responsibility for the prevention, detection and treatment of health problems in a manner that supplements or substitutes for professional services. ? The review concludes with some recommendations for nursing practice, education and research.     

A “Top Five” list for emergency medicine: a policy and research agenda for stewardship to improve the value of emergency care

United States health care costs are growing at an unsustainable rate; one significant contributor has been the overuse of health services. Physicians have a professional ethical obligation to serve as stewards of society’s resources and take responsibility for health care costs. We propose a framework for identifying overused services and a research and implementation agenda to guide stewardship efforts to demonstrate the value of emergency care. Examples of interventions to reduce the cost of emergency care along six value streams are discussed: laboratory tests, high-cost imaging, medication administration, intravenous fluids and medications, hospital admissions and post-discharge care. Structural and political hurdles such as the Emergency Medical and Active Labor Act mandate, medico-legal concerns, lack of provider knowledge about costs and economic conflicts are identified. A research agenda focused on identifying low value clinical actions and potential interventions for overuse reduction is detailed. A policy agenda is proposed for organized emergency medicine to convene a structured, collaborative process to identify and prioritize clinical decisions that are of little value to patients, amenable to improvement through standardization, and actionable by front-line providers. Emergency medicine cannot wait longer to identify areas of low value care, or else other groups will impose external standards on our practice. Development of a Top Five list for emergency medicine will begin to demonstrate our professional ethical commitment to our patients and health system improvement.